Optimization of Current Procedural Terminology Coding in Complex Genitourinary Surgical Specimens
Abstract
CONTEXT.—: Complex surgical specimens are associated with complex Current Procedural Terminology (CPT) coding.
OBJECTIVE.—: To assess and optimize the accuracy of CPT coding of complex genitourinary specimens at our institution.
DESIGN.—: Baseline CPT codes for nephrectomy and cystectomy surgical pathology specimens were examined during a 3-month period. Pathology reports were reviewed for accurate CPT coding, and commensurate tests of change were implemented. Post-test-of-change data were re-collected, analyzed, and compared to the baseline data.
RESULTS.—: Baseline data consisted of 71 genitourinary specimens (April to June 2021) and demonstrated undercoding in 46% (n = 33 of 71) of specimens, mostly in specimens with 2 or more billable organs. From findings in baseline data, we implemented test-of-change efforts consisting of awareness, education, and increased documentation and communication between all involved parties. Marked improvement was noted in the coding accuracy of specimens with 2 billable organs (pretest: n = 4 of 21, 19%; posttest: n = 14 of 21, 67%) and 3 or more billable organs (pretest: n = 0 of 16, 0%; posttest: n = 7 of 12, 58%) (P value = .002). Problematic areas included nephrectomy specimens resected with adrenal glands (pretest: n = 2 of 12, 17%; posttest: n = 12 of 14, 86%) and ureters for urothelial carcinoma (pretest: n = 0 of 10, 0%; posttest: n = 3 of 6, 50%), as well as regional lymph nodes commingled with resection specimens (pretest: n = 0…
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